Diabetic gastroparesis

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Diabetic gastroparesis is a complication of long-term diabetes characterized by delayed gastric emptying that is not associated with mechanical obstruction. Risk factors are inadequate glycemic control and obesity. Symptoms typically include nausea, vomiting, abdominal discomfort, and early satiety. Diabetic gastroparesis is a diagnosis of exclusion and is confirmed by scintigraphic gastric emptying. The mainstay of treatment is conservative management with glycemic control, dietary modifications, and avoidance of medications and substances that delay gastric emptying. Prokinetic agents may improve gastric emptying, whereas antiemetics can provide symptom relief. Patients with refractory symptoms may require surgery, gastric electric stimulation, or parenteral feeding.

See also “Diabetic neuropathy.”

• Diabetic gastroparesis is the most commonly identified cause of gastroparesis. ^[2]
• Affects 5% of patients with type 1 diabetes and 1% of patients with type 2 diabetes ^[3]

Epidemiological data refers to the US, unless otherwise specified.

• Poor glycemic control (e.g., sustained hyperglycemia > 200 mg/dL) ^[4]
• Obesity ^[3]

• Poor glycemic control, sustained hyperglycemia > 200 mg/dL → neuronal damage → impaired neural control of gastric function (e.g., interstitial cells of Cajal dysfunction, abnormal myenteric neurotransmission, smooth muscle dysfunction, vagal dysfunction) → antral motor coordination and function abnormalities (↓ antral contractions, pyloric spasms, abnormal antroduodenal contractions) → delayed gastric emptying
• Abnormal small bowel motility → ↑ or ↓ gastric compliance → delayed gastric emptying
• Autonomic neuropathy → abnormal gastric electrical activity and visceral perception

• Common symptoms ^[4][7]
  • Nausea and/or vomiting
  • Bloating
  • Upper abdominal pain
  • Loss of appetite
  • Early satiety
• Examination findings ^[3][8]
  • Abdominal distension
  • Epigastric tenderness
  • Succussion splash

Approach ^[3][4][9]

• Perform clinical evaluation to exclude differential diagnoses of gastroparesis.
  • Assess for clinical features of neurological diseases, autoimmune disease, or eating disorders. ^[4][9]
  • Review medication list for medications that delay gastric emptying (e.g., opioids).
  • Ask about history of bariatric surgery.
  • Consider laboratory studies, as indicated.
• Obtain upper endoscopy to exclude mechanical obstruction. ^[4]
• Perform confirmatory testing to observe delayed gastric emptying.

Laboratory studies ^[3]

• HbA1c: to assess glycemic control
• Depending on clinical features, obtain additional studies to rule out differential diagnoses of gastroparesis, including:
  • TSH: to assess for hypothyroidism ^[10]
  • CBC: to evaluate for infection, malignancy
  • Diagnostic studies for chronic pancreatitis

Confirmatory tests ^[4]

• Preferred: scintigraphic gastric emptying
• Alternatives
  • Wireless motility capsule test
  • Stable isotope breath test ^[2]
• Delayed gastric emptying is confirmed if studies show > 10% gastric retention after 4 hours. ^[4][11][12]

At least 48 hours prior to confirmatory testing, stop medications that affect gastric emptying, and initiate strict glucose control to prevent false negative or false positive results. ^[4]

• Alternative causes of gastroparesis
  • Idiopathic ^[4]
  • Postsurgical (e.g., after vagotomy or bariatric surgery) ^[9]
  • Medication-induced (e.g., opioids) ^[4][9]
  • Neurologic disorders (e.g., Parkinsonism) ^[9]
  • Infiltrative disorders (e.g., amyloidosis) ^[9]
• Differential diagnoses of abdominal pain, e.g.: ^[3]
  • GERD
  • Acute or chronic pancreatitis
  • Malignancy
• Other disorders
  • Eating disorders (e.g., avoidant restrictive food intake disorder) ^[4]
  • Cyclic vomiting syndrome or cannabinoid hyperemesis syndrome ^[4]
  • Thyroid disorders ^[3]

The differential diagnoses listed here are not exhaustive.

Approach ^[4][9]

• All patients
  • Initiate nonpharmacological measures to improve gastric emptying.
  • Refer to gastroenterology.
  • Screen for additional microvascular complications of diabetes.
• Persistent symptoms: Start pharmacological treatment.
• Refractory disease: Consider surgical referral or gastric electric stimulation.

Pharmacotherapy should be offered as a short-term treatment for diabetic gastroparesis; long-term use of medications is associated with adverse effects. ^[4]

Nonpharmacological management ^[4]

• Optimize treatment of diabetes to achieve glycemic targets for diabetes.
  • Gastroparesis can complicate the management of diabetes by causing: ^[7]
    • Poor absorption of oral antidiabetic drugs
    • Difficulties with timing insulin doses due to delayed food absorption
  • Select antidiabetic medications carefully as some drugs delay gastric emptying. ^[4][7]
• Initiate dietary modifications in consultation with a nutritionist. ^[4][7][9]
  • Small, frequent meals
  • Low in fat and fiber
  • Small particle size ^[13]
• If possible, prescribe alternatives for patients taking medications associated with delayed gastric emptying. ^[7]
• Avoid substance use (e.g., tobacco, alcohol, cannabinoids). ^[9][14][15]
• Acupuncture may improve gastric emptying and provide symptomatic relief ^[4]

Some medications used to treat diabetes (e.g., GLP-1 agonists, pramlintide) can delay gastric emptying. Consider alternative agents in patients with diabetic gastroparesis. ^[7]

Pharmacotherapy

Prokinetics ^[4]

• Used to improve symptoms and gastric emptying
• First line: metoclopramide
  • Severe symptoms: short course IV/IM metoclopramide
  • Mild to moderate symptoms: oral metoclopramide ^[16]
• Alternatives
  • Motilin agonists (e.g., erythromycin, azithromycin) ^[4]
  • 5-HT4 agonists, e.g., prucalopride
  • Domperidone ^[4][9]
    • Available outside of the USA
    • Within the USA, access is limited to compassionate use and requires special FDA approval.

Antiemetics ^[4]

• Improve symptoms (nausea, vomiting) but do not improve gastric emptying.
• Options include 5-HT3 antagonists (e.g., ondansetron) and NK1 receptors antagonists (e.g., aprepitant)

Central neuromodulators (e.g., haloperidol, nortriptyline) are not recommended at present because of a lack of evidence. ^[4]

Management of refractory diabetic gastroparesis

Surgery ^[4]

• Jejunostomy tube placement: may be performed for patients requiring enteral feeding ^[4]
• Venting gastrostomy: may be used for relief of symptoms (e.g., bloating, vomiting) ^[4][17]
• Gastric peroral endoscopic pyloromyotomy
• Other procedures (rarely performed): ^[3]
  • Partial gastrectomy or sleeve gastrectomy ^[18]
  • Gastrojejunostomy
  • Pyloroplasty

Intrapyloric botulinum toxin injections have been trialed in the past but are not currently recommended due to a lack of efficacy. ^[4]

Gastric electric stimulation (GES)

• Provides high-frequency electrical pulses to the stomach through leads that are implanted into the stomach wall to enhance gastric emptying ^[19]
• Evidence to support its use has been mixed. ^[4][20]

Parenteral nutrition ^[4]

• Consider in advanced disease.
• Continuing oral feeding alongside parenteral nutrition reduces morbidity and mortality.

• Electrolyte imbalance ^[21]
• Malnutrition ^[21]
• Increased risk of postprandial hypoglycemia because of delayed food absorption ^[7][21]

We list the most important complications. The selection is not exhaustive.